Peter D. Kramer

Fanning the flames of paranoia

A psychiatrist wonders how a culture of Birthers and Truthers feeds the delusions of people like Jared Loughner

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Fanning the flames of paranoiaJohn Balazek of La Plata, Md., attends a rally by the U.S. Capitol in Washington Saturday, Oct. 23, 2010. Participants at the rally, organized under the name of Obama birth certificate rally, call into question the president's eligibility. (AP Photo/Jacquelyn Martin)(Credit: Jacquelyn Martin)

Like everyone else, in the wake of the killings in Tucson, Ariz., I’ve been thinking about paranoia. I have worked with the disorder for the whole of my psychiatric career. Early in my residency, at Yale, I was identified as “good with paranoids.” I doubt that I began with any special talent. The claim that I did allowed colleagues during residency to avoid these patients and send them my way.

Diagnosis was less critical then, 30-odd years back, but the people I treated probably had paranoid schizophrenia, bipolarity and what is now called delusional disorder, formerly paranoia. My favorite was an annoyed and critical woman who said that CIA agents had damaged her car ignition and then followed her everywhere on the bus, so that she could not travel to see me — and why should she, since I was probably part of the conspiracy? When the Blizzard of 1978 swept through New England, I was held over at the Connecticut Mental Health Center — actually, I had managed briefly to get away and had used cross-country skis to return on the empty New Haven streets. At her appointment time, there, all alone, was my beleaguered patient, sitting on the molded Eames chair in the darkened hallway, waiting for her opportunity to give voice to her suspicions.

The experience in my training years made me comfortable with paranoia. As a result, I have always had one or two paranoid patients on the roster in my private practice here in Providence, R.I. I should stress that no one I see resembles Jared Lee Loughner. I travel a good deal, and I can’t leave the covering doctor with potentially violent patients. When my patients have schizophrenia or related conditions, they tend to be the most accomplished, most reliable, and nicest people to suffer these terrible afflictions. Their needs are serious enough.

Not much specific is known about how to treat paranoid patients. Generally, they don’t come in hoping to lessen their delusions, which can be wholly convincing to them. They want relief from depression or insomnia — or from an employer who has insisted they get help. Their mood symptoms may respond to medication, and they may even become less isolative, but generally the system of thought does not budge. After months of trials of different drugs, the patient will be less agitated and less pained but still solidly convinced that he is being watched and threatened. Always, too, there are prices to be paid in terms of medication side effects.

Paranoia the disease and paranoia the symptom are something like orphan conditions, understudied and therefore subject to untested remedies. You can go to a large general psychiatric meeting and not find a single lecture on the topics. Current research techniques have opened windows onto autism and schizophrenia; those good beginnings have led to funding for further studies. Paranoia simply has not been the subject of “scientific opportunity.” The condition is probably highly heterogeneous, in terms of what can cause it, and no one has found a way in.

My paranoid patients throw me back on skills I learned early in my training, when the efficacy of psychotherapy was never in question and the use of medication was a sign of desperation on the part of the doctor. We sit and talk. I try not to make matters worse. (One of my mentors stressed that in the face of paranoia, empathy consists in not offering strikingly accurate insights.) Once we have established what therapists call a working alliance, I will try to induce the tiniest wakening of doubt about conspiracies. I consider this effort crucially important, but it is fraught with difficulty. I lose patients over it; seeing that I don’t accept their premises, they flee. Others stay and become heartbreakers. They slide ever further into their delusions. I conduct a rear guard action, trying to slow the march toward ever greater certainty about the dark forces.

If I cannot induce doubt, I try to make clear to the patient that others do not believe as he does. Likely he will lose his job if his beliefs emerge even in subtle fashion — and it is critical for him to keep his job, however humble. If a supportive family is available — and sometimes it is not, since genetics play their role — that safe haven can be of enormous help to patients. But my focus is generally on employment. Work is where skills count, where you can be valued despite your quirks. Work is where, if you are lucky, people will come to know and like you over time, even if you are “hard to live with.” Work is where you can interact with people without having them intrude.

Beyond the workplace, another source of unobtrusive connection (so I find) is radio. Television serves, too, as does the Web, but to a lesser extent. I have written elsewhere about how a quite troubled patient with no interest in cars found solace in the company of hosts Tom and Ray Magliozzi when she listened to “Car Talk.” Over the years, that program has charmed various of my paranoid patients. I see “Click and Clack” as co-therapists; they demonstrate a relaxed way of responding to life’s inevitable frustrations. On the whole, public radio has this reasonable tone. I don’t love it when patients spend the morning in bed listening to NPR, but there are worse influences. I certainly have had many patients who are mesmerized by the rant media and the politicians they feature and who come in wanting to discuss the outrage of the moment. I find that attachment less reassuring.

Because of what he is accused of doing, Loughner is an unsympathetic, even a horrifying figure. But Loughner’s efforts to find work struck a responsive chord in me, as a clinician. According to the Wall Street Journal, Loughner had asked posters to an online forum, “How many applications …. is a lot?” He had listed 21 retail outlets he had approached, including Domino’s Pizza and Wendy’s. He said he had lost or left jobs at Peter Piper Pizza, Quiznos and others. Although Loughner was disturbed, he did not at that point sound like an utterly alienated man — rather, one looking for acceptance somewhere. The attempts to study at Pima Community College also suggest some remnant of openness to social integration.

What did Loughner watch or listen to? We do not know. The Web and the media contain ideas as extreme as anyone might want. According to Newsweek, Loughner posted anti-government writings and videos based on the views of the right-wing conspiracy theorist David Wynn Miller. Did more mainstream media influence Loughner? Did fear- and hate-mongering pundits or politicians play a role?

Respected colleagues and columnists have been quick to say no. Shall we give Fox News, Glenn Beck, Sarah Palin and the others a quick pass? It is true that the biology of mental illness has its own imperative. But along with most other people, I do imagine that in a general sense social forces can mute, inflame or redirect impulses. That’s what the time in the clinical office is about, in part: the use of interpersonal influence to moderate or channel emotions. Much political speech has the same aim.

The work that I do makes me suspect that creating a hysterical political environment has its costs. Many writers have commented on the corrosive effects of casual references to violence, along with the demonization of public figures and the glorification of gun ownership. I want to add a further consideration, implicit in the others, but worth separating out: tolerance, in the public sphere, for paranoia itself.

Two days before the shooting spree in Tucson, Brian Williams asked House Majority Leader John Boehner whether he would confront the claim that Barack Obama is not a natural-born citizen. In measured tones, Boehner gave a coy response: Hawaii’s word is good enough for him, but it is not for him to tell others what to think. Watching the clip when it first aired, I thought, that stance must be risky, using a wink and a nod to leave the door open to patent falsehoods. I meant risky politically, in every sense. After all, the birther claim is a true conspiracy theory, dependent on the premise that government institutions are abetting a complexly plotted fraud.

When they argue their case that the plots they discern are real, paranoid patients arrive armed with examples of views more outlandish than their own. After all, my patients do not deny Darwinism or global warming. If they claim that the president of the United States is a conspirator secretly intent on socialism, it’s a sign that they are far down a sad road. The public embrace of implausible beliefs creates a context of credulity. For my purposes, journalists and politicians who countenance conspiracy theories are the opposite of co-therapists; they are enablers. They stand as exemplars of a mode of being that scorns doubt, celebrates grievances, and reframes ordinary disagreements as indicators of sinister intent.

In the context of demonization and demagoguery, this embrace of paranoia helps to compose a politics of constant rage. It is convenient and convincing to say that no particular public figure is directly implicated in Loughner’s actions. But I wonder whether finally the imputation of some responsibility is so easy to shed.

Tin ear

Perhaps if Gail Sheehy listened better, she'd find that Hillary doesn't suppress emotion -- she just doesn't get it.

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Tin ear

The difficulty with Gail Sheehy’s biography of Hillary is right there in the opening sentence: “When under siege she rises early, dresses quickly, and cauterizes her emotions.”

Forget that the metaphor is infelicitous. (I suspect the idea is that emotions are like blood; but then to block them the cautery should be applied to their source, perhaps the limbic system.) Set aside that the chapter is about an appearance on “Today” in January of 1998, when, according to Sheehy, Hillary still disbelieved the Monica allegations and so could express affect freely, namely anger at Bill’s enemies. Ignore that much of the rest of the book draws on psychoanalytic concepts (splitting, dissociation, denial) that presume unacceptable feelings are unconscious and so do not need willful stanching.

The insuperable problem in that first sentence, as in the rest of the book, concerns the sort of knowledge required for one person to be sure that on a given morning — or characteristically, on many mornings — another person has shut off disturbing emotions. Sheehy promises the reader a close, personal, highly particular understanding of the first lady’s emotional life, and then (thankfully, one might add) she cannot deliver.

Sheehy’s intent in “Hillary’s Choice” is to write psychobiography. She never focuses for long on politics. The question that interests her regards the first marriage: Why did Hillary pick Bill and why has she stayed with him? The answer Sheehy proposes is at the level of the hypotheses of a psychotherapy: Because in childhood her father did not give her enough praise, in adulthood Hillary became addicted to an emotionally abusive relationship. To satisfy that addiction, Hillary has had to ignore the obvious — her husband’s character flaws and his philandering. The choice referred to in the book’s title is “not to know what she knew.”

For this analysis to be credible, it would need to be buttressed by evidence of a most intimate sort. Yes, it is a commonplace of pop psychology that empathic failures between parent and child, even ones that fall far short of outright abuse, create in the child an inner emptiness often filled in later life by addiction. But that belief is not an unquestioned truth; it is a distortion of theories largely traceable to a variant of psychoanalysis called self psychology.

The central concept of self psychology is “mirroring,” an exact resonance between mother (usually) and child. The theory has it that imperfect mirroring causes deficits in the child’s self. Treatment, under this model, requires an effort at exquisite attunement on the part of the therapist. The self psychologist wonders not how most people might have experienced an event but how this patient did in fact experience it. The empathic stance requires openness to idiosyncrasy. What might seem an insult to most people may go unnoticed by this patient, and what conventionally seems supportive may cause outrage. Surprise is a common experience in the practice of self psychology — the constant rediscovery of difference.

Of course, biography is about idiosyncrasy and difference. Like psychotherapy carefully done, skillful biography will show evidence of the most subtle listening. Sometimes a writer will have access to a subject’s diary or (as in the case of Diane Middlebrook’s study of Anne Sexton) even tapes of a subject’s psychoanalysis; like a therapist, the biographer sits with this intimate testimony until it gives forth an impression of ways in which the subject’s character or choices reflect her development. But despite hundreds of interviews, Sheehy has failed, with a single exception, to find anyone able or willing to give convincing evidence about how Hillary’s mind works.

“Hillary’s Choice” is very much biography from the outside in, a method that is especially unsatisfying in the case of a modern political figure whose public appearances are scripted. The sort of context Sheehy provides is immediate and journalistic. A typical sentence relies on irrelevant local color to lend verisimilitude: “An hour after giving Bill his slap on the wrist, Hillary — soft and feminine — entered the Pork Producers Rib Feed in Pierre.” “Hillary’s Choice” often has the feel, and the substance, of an extended women’s magazine article, a just-between-us-girls dishing about Hillary’s strengths and foibles, in which continual references to what Hillary wore are meant to signal truths about psychic change. When the “First Bosom,” as Sheehy calls it, is revealed by dicolletage, we are to understand that Hillary is at last in touch with her femininity or that she has become carefree and assertive — in brief, ready to reclaim her man and have a run at the Senate.

Sheehy does provide a private look at Hillary in college, and here she has achieved a journalistic coup, albeit one that may make readers uneasy. While at Wellesley, Hillary corresponded extensively with a close high school friend, then a Princeton undergraduate, John Peavoy. Sheehy was given access to 30 of these letters. They reveal a young woman who is driven, intellectually curious and often disdainful of those around her. Hillary is in a constant identity crisis centered on her ambitions. Will she be a mainstream political leader or a social reformer? Her type, she seems to decide, is the “compassionate misanthrope,” someone out to help mankind but who does not like particular people very much.

If ethical squeamishness can be put aside, what a reader would most like is access to fuller texts of these letters. As excerpted, they are noteworthy for what they lack, the sturm und drang of adolescence, joy or disappointment in relationships, evidence of any insight into other people, even Peavoy. Here (and really only here — Sheehy rarely manages to breach Hillary’s privacy) is the sort of particularity that might interest a self psychologist: Few undergraduates would send off 30 letters empty of personal upset except as it relates to coursework and career.

Hearing Hillary’s private voice in this correspondence, it is hard to put stock in this business of cauterizing emotions. Where did Sheehy get the impression that Hillary needs to squelch her feelings? Young Hillary Rodham has self-doubts, and she suffers a minor February depression, characterized by sleeping too much — she is quite open with Peavoy about this. But for the most part she does not “do” — or get — affect. Hillary wonders what happiness is. She is outraged by Wellesley’s muted reaction to the murder of Martin Luther King, but there is no hint in these letters of any personal feeling that would bear suppressing.

Though Sheehy does not see it this way, she has gathered reams of testimony to Hillary’s lack of emotional awareness. Commenting on one or another social interchange, friend after friend says that Hillary was just out of it. In childhood, Hillary often appears socially inappropriate, bragging and putting other kids down. Of Hillary in adult life, one colleague says, “She can talk about the finer points of education policy but not notice her best friend might be suicidally depressed.”

This last comment is especially disturbing in light of Vince Foster’s relationship to Hillary. According to Sheehy, Foster adored Hillary, and she was as close to him as she ever was to anyone. A White House staffer tells Sheehy that Foster was obviously nonfunctional at the end. Hillary seems not to have noticed — although Sheehy has nothing to say on the topic.

Nor has Sheehy a clue as to how Hillary responded to Foster’s suicide. Here is Sheehy’s effort: “One can only speculate on the complex emotions Hillary might have felt: sadness, loss, guilt, but also anger …” Sheehy’s method is to say that her subject is particular and extraordinary, but then to attribute to Hillary a conventional response to any given event.

The central thesis of the book, that Hillary so craved a father’s affection that she had to blind herself to the flaws of men she loved, seems similarly arbitrary — unanchored by any personal, private evidence. I do not pretend to know more than the next person about Hillary, but reading “Hillary’s Choice,” it strikes me that the critical relationship to her father may not be trauma but resemblance.

Hillary seems like Hugh Rodham in not being especially focused on the nuances, or even the broad strokes, of social intercourse. She may be less self-destructive than constitutionally insensitive — mistaken in her reading of social cues and, at the same time, focused on career rather than romance. In a man, these traits would be unremarkable; men who have them often marry, and stick with, women who are needy and flamboyant. The less emotional spouse needs enlivening and is willing to pay a price to get it.

From the outside, it does seem a terrible shame that Hillary married Bill. She was a brilliant student and a committed liberal — the sort of woman we could have used in politics over the past 30 years. Her friends protested bitterly when she drove to Arkansas to marry Bill. Hers is a choice too many bright women in her generation made, at a critical moment letting go of a chance at an independent career. Many pressures led in that direction. Hillary made her move willfully and without looking back. Whether she did it with her eyes open is less clear.

As psychological evaluation, Sheehy’s book is hard to make sense of. She seems to have relied in part on the judgments of an unnamed mental health professional close to the Clintons (my colleague Susan Blumenthal is mentioned in the acknowledgments as having “cooperated to the degree [she] could without incurring the first lady’s wrath”), but not to have digested the elements of the assessment.

Throwing its unsubstantiated psychological formulations aside, the book has interest precisely because it is confusing. Beyond the unnamed mental health professional, no one interviewed knows what to make of Hillary. Was she prematurely adult as a child, or reluctant to grow up? Is she a political genius or a bungler? Perhaps the important evidence about Hillary is her failure to succumb to biography — her remaining out of focus.

Hillary may be a tragic everywoman, a romantic felled by injury and addiction; but Sheehy does not seem to know Hillary in a way that would allow her, or her readers, to decide. People are hard to know. Hillary might be Richard Nixon, hungry and self-defeating, but then again she might (surprisingly) have about her a bit of Ronald Reagan. Yes, she seems a fuller person than Reagan did. What I have in mind is Reagan’s ability to elicit projection. Those who liked him ascribed feeling to Reagan — sympathy, concern — that was invisible to those who disliked him. I wonder about Hillary and her emotional conflict. Did she make a choice, or did she just mistake aspects of her husband’s character?

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